Your treatment options, compared honestly

Start here: what you are actually choosing between

Kidney failure has four legitimate answers, and a fifth that usually sits alongside one of them. NICE is explicit that a choice of kidney replacement therapy or conservative management must be offered to everyone likely to need it. If you have been presented with one option and told it is the only one, that is not how this is supposed to work.

Before the comparison, one hard truth, because everything else follows from it. No form of dialysis restores normal kidney function. In the words of the US National Institute of Diabetes and Digestive and Kidney Diseases, haemodialysis "can replace part, but not all, of your kidney function". Three sessions a week of four hours is an intermittent approximation of an organ that never stops. That is why the diet, the fluid limits and the medicines persist whichever path you take, and it is why the choice is really about how you want to live, not only about how long.

The comparison, side by side

In-centre haemodialysis

Blood is pumped out of your body through a filter, which removes waste and excess fluid, and then returned. Typically three times a week, about four hours a session, usually Monday, Wednesday and Friday, or Tuesday, Thursday and Saturday.

What it gives you

• Trained nurses do the treatment. You do not have to learn anything technical, and you do not need a partner or a carer trained up.
• You are observed by clinical staff three times a week, so problems are picked up early.
• No equipment, no supplies, and no plumbing changes at home.
• Company. This is genuinely valued by many people, and it is quietly one of the main reasons some choose it over home therapy.

What it costs you

• It is the least flexible option. Work, family and travel all bend around the unit's rota.
• The intermittent pattern means fluid builds up between sessions and is then removed in a rush. That is what causes the blood pressure crashes, the cramps, and the washed-out feeling afterwards.
• It carries the tightest fluid and diet restrictions of any option.
• The two-day gap between the last session of one week and the first of the next is when fluid and potassium build up most, and it is the interval clinicians worry about.

It suits people who cannot or would rather not do their own treatment, people without a suitable home setting or support, people who are medically unstable, and people who genuinely prefer the structure and the company.

Home haemodialysis

The same treatment, done by you (with or without a trained partner) in your own home. Schedules vary: three times a week or every other day for 3 to 5 hours; short daily sessions of 2 to 4 hours, five to seven days a week; or overnight while you sleep.

What the trials actually showed

Be careful with anyone who tells you more dialysis is simply better. The evidence is more interesting than that.

• The FHN Daily Trial compared six sessions a week with three, in 245 patients over a year. It found benefit on both of its main outcomes, plus better blood pressure and phosphate control. But it also found more procedures on the vascular access in the frequent group. More needling is more wear.
• The FHN Nocturnal Trial, in 87 patients, found no significant effect on either of its main outcomes, though blood pressure and phosphate control did improve.

The honest summary: more frequent or longer dialysis is probably better for symptoms and for the numbers, the evidence on survival is not conclusive, and your access takes more punishment.

What it gives you, and what it costs

It gives you control of your own timetable, gentler fluid removal (so fewer crashes and less post-dialysis flatness), better blood pressure and phosphate control, a more liberal diet and fluid allowance, and no travel to a unit.

It costs you this: you have to learn to put needles into your own fistula, and run a machine. Training takes weeks, and for many people the needling is a real psychological hurdle, not a small one. You need space at home, storage for supplies, and sometimes plumbing or electrical work. If you have a care partner, the burden on them is real and is frequently under-acknowledged. And you will be alone in a room with a machine that has your blood in it, so alarms and emergencies have to be rehearsed until they are boring.

It suits people who want control and flexibility, who have the dexterity and the eyesight, who have a stable home, and who would rather learn something hard than lose the time.

Peritoneal dialysis (CAPD and APD)

Peritoneal dialysis uses the lining of your own abdomen, the peritoneum, as the filter. Dialysis fluid runs into the abdominal cavity through a soft catheter, sits there while waste and excess fluid cross into it, and is then drained out and replaced. That cycle is called an exchange. There are no needles, and no machine pumping your blood.

The two forms

• CAPD is done by hand, with no machine, at least four times a day. Each exchange takes about 30 to 40 minutes, with a dwell of 4 to 6 hours or more in between, including a long overnight dwell. You stop what you are doing, four times a day, in a clean space.
• APD uses a machine, a cycler, which performs the exchanges while you sleep, typically 3 to 5 cycles a night. You connect at bedtime and disconnect in the morning, and your days are mostly free.

What it gives you

• It is done at home, by you, on your schedule. There is no unit rota.
• It is gentle and continuous. Fluid comes off slowly rather than in a four-hour rush, so there is no crash, less cramping, and much less post-treatment exhaustion.
• It usually preserves your remaining kidney function for longer, which in turn keeps your diet and fluid allowance more generous.
• Diet is less restricted, particularly for potassium. Peritoneal dialysis removes potassium continuously, and some people on it are told to eat more potassium, not less.
• No needles.
• It is the easiest modality to travel with, because fluid can often be delivered to your destination.

What it costs you

• Peritonitis. This is the defining risk, and it is the reason the technique has to be right every single time, with hand washing and a mask and no shortcuts. Cloudy drained fluid with tummy pain is peritonitis until proven otherwise.
• A permanent tube leaving your abdomen, with the implications that has for body image, for swimming and for bathing.
• Every day, with no day off. Some people find that relentlessness harder than three fixed days a week.
• Weight gain and effects on blood sugar, because sugar (dextrose) is absorbed from the dialysis fluid. This matters especially in diabetes.
• Hernias and fluid leaks, because of the raised pressure inside the abdomen.
• Protein is lost into the dialysate, so people on peritoneal dialysis need more dietary protein, not less.
• Boxes of fluid to store at home.
• The membrane can tire. Over years the peritoneum can stop removing enough fluid, and a switch to haemodialysis becomes necessary. Peritoneal dialysis is often not a lifetime modality, and it is better to know that at the start than to experience the switch as a failure.

Some conditions make peritoneal dialysis difficult or impossible: a membrane that has already failed, dense adhesions inside the abdomen, an unrepairable hernia, an active infection in the abdomen, or severe malnutrition. But the lists vary between units, and many entries on them are barriers rather than absolute bars. Assisted peritoneal dialysis, where a nurse or a carer does the exchanges, opens it to people who cannot manage alone. If you have been told you are not suitable, it is reasonable to ask whether that is a fact about your body or a fact about the local service.

Conservative care: the option people are not told about

Conservative care, also called supportive care, means treating kidney failure actively withoutdialysis or a transplant. NIDDK puts it plainly: "You have the right to decide how your kidney failure will be treated. You can choose conservative management instead of dialysis or transplant." NICE requires that it be offered as a genuine option.

It is not doing nothing. It is active management of anaemia, of acid build-up, of fluid, of itching, nausea, breathlessness and pain. It is blood pressure control, a serious medicines review, dietetic support, planning ahead, and psychological, spiritual and carer support. It is everything except dialysis.

The honest summary we would give, and we have thought about how to put this:

For a younger, fitter person, dialysis very probably buys meaningful extra years. For someone who is very old, frail, or carrying several serious illnesses, dialysis may buy little or no extra time, and it will certainly cost time: hospital visits, procedures, and hours spent recovering from each session. Some people in that position live longer on dialysis. Some live about as long, but spend more of it in a hospital chair.

That trade-off belongs to the person living it. It is not the clinician's to make, and it should be revisited as things change, not decided once and never mentioned again. Choosing conservative care is not giving up. For some people it is the choice that protects what is left of their life.

And the fifth path: transplant

A kidney transplant gives the best long-term outcomes for people who are suitable for it, and it can sometimes be done before dialysis is ever needed. But it sits alongside these four rather than replacing them, because most people need dialysis while they wait. The work-up takes months, which is why the question should be asked early. We have given it its own guide.

How to make the decision

Not by picking the option with the best statistics, because the statistics comparing modalities are confounded by who gets chosen for each. Try these questions instead, and take your answers into the clinic with you:

• What matters most to me: my time, my independence, my safety, or the company of other people?
• Am I willing to learn a technical task, and to needle myself, in exchange for freedom?
• Who is at home with me, and what is fair to ask of them? Have they been asked?
• Do I want to keep working, and what would each option do to that?
• How do I feel about a tube in my abdomen, against needles in my arm?
• How far is the unit from my home, and how would I get there three times a week, every week, in the rain?
• If I am frail and elderly, has anyone honestly discussed conservative care with me, or has it simply been assumed that I will dialyse?

Ask to speak to the home therapies team, even if you think you are not a candidate. Ask to speak to someone already on each treatment, which most units can arrange and which is worth more than any leaflet. And ask what would happen if you changed your mind in a year, because the answer is usually "then we would change it".